Obstetric Brachial Plexus Injury (OBPI), also known as Birth Brachial Plexus Injury (BBPI), refers to the paralysis of one arm from the neck down in an infant shortly after birth. This condition occurs due to an injury to the Brachial Plexus while the baby passes through the birth canal.

Following birth, newborns are routinely examined by pediatricians in hospitals. Any loss of movement in the arm or hand is identified and monitored. If arm palsy is detected, parents are advised to consult a Plastic surgeon for confirmation of the diagnosis and potential early intervention.

In rural areas where immediate post-birth evaluations are not feasible, arm paralysis in children with BBPI often goes unnoticed initially by parents. As the child grows and experiences difficulty performing normal hand functions, they are taken to a physician. Due to a lack of awareness, even healthcare professionals may fail to refer the child to the appropriate specialist promptly, leading to delayed intervention and suboptimal outcomes.

Several risk factors increase the likelihood of a child developing BBPI, including:

• Large-for-Gestational-Age Infants (Big Baby)
• Multiparous Pregnancies
• Previous Deliveries Resulting in Brachial Plexus Birth Palsy
• Prolonged Labor
• Breech Delivery (Feet First)
• Assisted Delivery (Using Vacuum or Forceps)
• Difficult Deliveries

Obstetrical brachial plexus palsies are categorized into two major types based on the extent and severity of the injury:

Upper Brachial Plexus Palsy (“Erb’s Palsy”) – Involving the C5 and C6 nerve roots and sometimes C7 as well. This condition results in no movement at the shoulder and elbow joints but normal hand grip function.

Complete Brachial Plexus Palsy – Involving all nerve roots from C5 to T1, leading to a complete lack of movement at the shoulder, elbow, and hand, along with complete sensory loss.

In most cases, babies with a brachial plexus injury regain some or full movement in the affected arm. Mild cases may improve without treatment. However, the concept of “wait and watch” has been replaced with early intervention to achieve better outcomes. Early intervention has proven to be more effective, aligning with results observed in adult patients after injury.

Nerve repair outcomes in children differ from those in adults. Paralysis in children due to obstetric causes is usually not complete, with some fibers undergoing reinnervation due to neuromas crossing and resulting in minimal muscle activity. This innervation keeps the muscles viable and suitable for later nerve surgery.

Nerve surgery in children with BBPI typically involves two main approaches:

Nerve Repair with Nerve Grafts: Using a nerve from another part of the body (usually the back of the foot and leg) to patch an injured nerve in the brachial plexus.

Nerve Transfer: Connecting a healthy nerve outside the brachial plexus or an intra-plexus functioning nerve to the nerve whose function needs to be restored. Nerve transfer has the advantage of facilitating faster muscle reinnervation.

• In global palsy, where the entire brachial plexus is affected, surgical exploration involves identifying ruptured nerves, removing scar tissue from the nerves, and performing nerve repair using grafts from the leg. In cases where proximal nerve roots are unhealthy, nerve transfers such as intercostal nerve or C4 nerve transfers may be performed.
• In partial C5–6 or C5-6-7 palsy, where elbow flexion and shoulder abduction are affected, nerve transfers are aimed at regaining both of these movements. Procedures like the Oberlin transfer for biceps recovery and spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer for shoulder movement (infraspinatus and supraspinatus muscle function) are commonly employed. Additionally, transferring a nerve supplying one of the triceps’ heads to the axillary nerve can improve shoulder abduction.